January/February 1999                                                                                  Volume 3 Number 1

Happy New Year !

Inside this Newsletter

Last year the majority of our new members were new to the field of Medical Billing and asked for basic coding information. This issue will focus mainly on what it means to be a Medical Billing Specialist. Starting with the next issue we will have regular articles on coding in addition to industry changes and reimbursement trends.

We wanted to take this opportunity to wish you all a happy and healthy new year.

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Medical Records are legal documents and as such must be treated with utmost care.  Rules to follow when handling these sensitive documents include:

The retention of medical records is governed by state and local laws. Generally the minimum time is 5-10 years. According to the Nevada State Board of Medical Examiners the Nevada Statutes and Regulations for patient document storage is 5 years. However, It is a good policy to retain medical records indefinitely. Documentation records, such as X-rays, should also be stored indefinitely. Deceased patients’ charts should be kept for at least 5 years.

As we mentioned in an earlier CodeTrends, providers can now reduce boxes of inactive patient files to a single CD ROM disk. For more information on Data conversion to CD ROM, please contact our office at 702-648-8939.

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Practice & Provider Identification

Federal and state programs as well as many commercial insurance companies, assign identification numbers to physicians and practices who provide services to their patients. Medicare, Medicaid, Blue Cross, Blue Shield, CHAMPUS, and managed care plans issue provider numbers which must be used on insurance claim forms. For example:

	A state license is given to each physician practicing within the state. Example: 12345
	The Internal Revenue Services gives each physician within a medical group or solo practice their own federal tax identification number for income tax purposes. Example: 88-1234567.
	The Internal Revenue Service gives physician groups practicing together at one location an employer identification number (EIN). Example: 88-1234567.
	A physician in solo private practice may be issued a taxpayer identification number (TIN) which is identical to their Social Security Number. Example: 123-45-6789.
	The Health Care Financing Administration (HCFA) gives each physician a Medicare unique physician identification number (UPIN). Example: A12345, DCB123 or 49T123.
	Providers under contract to Medicaid have unique numbers. Example: 36-0123456.
	Providers under contract to Blue Cross and Blue Shield have distinctive numbers. Example: NV1234.
	Medicare (Part A) Fiscal Intermediaries (FI) issue providers a provider identification number (PIN). Example: AAA12345
	Additionally, many providers have specialty licenses, anesthesia licenses, railroad retirement licenses, CHAMPUS numbers, durable medical equipment (DME) numbers, and commercial numbers.

Your practice management system should be able to record each of these numbers. In your practice setup, tell the system which provider identification number to use for each type of insurance.

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Ethics

Medical Ethics has become hotly debated since the Balanced Budget Act (BBA) and the Health Insurance Portability and Accountability Act (HIPAA) were enacted. It is the coder’s responsibility to inform administration of unethical or possible illegal coding practices. It is illegal to report incorrect information to government funded programs such as Medicare, Medicaid, and CHAMPUS. However, it is unethical to report incorrect information to private insurance carriers.

Some examples of illegal or unethical coding are:

	Upcoding to increase payment when the case documentation does not warrant it. (Many providers under document, which forces the biller to down code, reducing office revenue.)
	Coding procedures for payment which were not performed. (Performing a single X-ray and charging for a 3 X-ray series.)
	Billing for services not provided. (Also know as phantom billing.)
	Unbundling services into separate codes (exploding charges) when a single code is available. (Charging for a sterile tray when performing surgery.)
	Altering fees on a claim form to obtain higher payment. (If your office fees are $60 and Medicare allowable is $65, you can not charge Medicare patients $65.)
	Coding a service differently in order to have it covered. (Well baby check will not be covered by some carriers, by coding an office visit due to a diagnosis the visit will be covered.)
	Forgiving deductibles or co-payments. As we mentioned in an earlier CodeTrends, routinely waiving or reducing coinsurance or deductibles could be considered fraud under the Medicare and Medicaid anti kick-back statutes. (The only exception is if the provider has a patient has sign a personal financial hardship agreement.)
	Billing for procedures over a period of days when all treatment occurred during one visit. (Split billing schemes.)
	Changing the date of service. (If a persons coverage expires the end of the month and they are not seen until the first of the next month it is fraudulent to back date claims.)

As we discussed in an earlier CodeTrends, Fraud is the intentional deception or misrepresentation of data which could result in some unauthorized benefit. It is a felony and if detected, financial or prison penalties can be imposed. If a Medicare or CHAMPUS case is involved, then the fraud becomes a federal offense.

Nancy-Ann Min DeParle, HCFA Administrator, stressed that "...the Health Insurance Portability and Accountability Act of 1996 has sanctions and Civil Monetary Penalties (CMPs) which may be assessed for coding errors that the person knows, or should know, which will result in greater payments than appropriate." She went on to say, "I want to assure you that physicians will not be punished for honest mistakes and we will not make referrals to the Office of the Inspector General (OIG) for occasional errors.... Sanctions are intended for physicians who act in "deliberate ignorance" or "with reckless disregard" of the truth or falsity of information. For criminal penalties, the standard is that the provider has "knowing and willful" intent to defraud the government."

Your role as an insurance billing specialist is to complete the insurance claim accurately and to facilitate reimbursement for your provider. We can not stress strongly enough that the biller and coder will not escape liability by pleading ignorance. When an insurance billing specialist bills for a physician and completes the insurance claim form with false information, they may be found guilty of conspiring to commit fraud. It is not necessary to receive monetary profit from a fraudulent act to be judged guilty.

For example, if an employee knowingly submits a fraudulent Medicare claim at the direction of the provider and the practice is subsequently audited, the provider and the employee can be brought into litigation by the state or federal government. All insurance billing specialists should check with their physician employer as to whether they are covered under the medical professional liability insurance policy. If you are not covered, or if you are an independent billing service, it is suggested you look into Errors and Omission Insurance.

Medicare as Secondary Payer

Some people who have Medicare also have group health or other types of coverage which may make Medicare a secondary payer on their health care claims. These situations include:

Medicare is the secondary payer for beneficiaries 65 and older who are employed and have an Employer Group Health Plan (EGHP) through their current employer with over 20 employees, or have an employed spouse of any age who has an EGHP through their current employer.

The Patient has the option to reject the plan offered by the employer. If they reject the health plan, Medicare will become the primary payer.

Medicare is the secondary payer for certain disabled people who have premium-free Medicare Part A and are covered under a health plan through their current employment or the current employment of a family member. This secondary payer provision applies to Large Group Health Plans (LGHP) with 100 or more employees.

Worker’s Compensation is the primary payer for items and services due to a work related illness or injury. Medicare is the responsible payer when Worker’s Compensation benefits have been exhausted or when services are not covered under Worker’s Compensation.

The Federal Coal Mine Act, enacted in 1973, established medical benefits for coal miners with black lung respiratory conditions. Black lung benefits are considered worker’s compensation benefits.

Medicare is secondary payer (regardless of employment and the number of employees).

The original End Stage Renal Disease (ESRD) legislation, enacted in 1981, established Medicare as the secondary payer for a 12-month coordination period (extended to 18 months in 1990) starting when the beneficiary became entitled to Medicare solely on the basis of ESRD AND is covered by a Group Health Plan.

Patients who have both Medicare and Veterans benefits may choose to get treatment under either program. They must choose one program each time they need care. In certain circumstances, low income veterans may also become eligible for medical benefits under the VA program.

CHAMPUS is the Civilian Health and Medical Program of the Uniformed Services. It covers civilian hospital services and services of civilian doctors, suppliers, and other providers. The program is for retired members of the uniformed services, spouses and children on active duty, and retired or deceased members. Most CHAMPUS beneficiaries who become eligible for premium-free Medicare Part A lose their CHAMPUS eligibility.

Medicare is the secondary payer if services are furnished by a federal provider such as a military hospital.

Legislation enacted in 1980 made Medicare secondary to automobile, no-fault, and liability insurance.

Medicare may make a conditional payment if the other insurer will not pay within 120 days. In those cases, when the auto, no-fault, or liability insurer pays, Medicare recovers its conditional payment.

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Last modified: Tuesday June 03, 2008.